Envelope for Upper-Extremity Injuries

[Pages:4]Framework Johns Hopkins Orthopaedic Surgery

NEWSFROM JOHNS HOPKINS MEDICINE

Spring 2017

Pushing the Envelope for Upper-Extremity Injuries

ADVANCES AT JOHNS HOPKINS MEDICINE

Vascularized bone grafting

Prosthetic design

Science of chimerism

Limb Transplant

John Ingari, left, operates with surgical technician Lauren Powell, middle, and orthopaedic surgery resident Lara Atwater, right.

Post-op

When orthopaedic surgeon John Ingari came to The Johns Hopkins Hospital two years ago, he brought 25 years of experience as a surgeon in the U.S. Air Force. What he found at Johns Hopkins was the opportunity to combine this expertise with that of clinicians across disciplines to treat patients with the most complex upper-extremity injuries.

"At Johns Hopkins, we're always asking, how do we push ourselves forward?... No surgery is mundane."

?John Ingari

Such conditions include scaphoid nonunions, in which there is no blood supply to the scaphoid. Ingari is preparing to publish his own technique for vascularized bone grafting in such patients. He also recently worked as part of the Johns Hopkins hand/ arm transplant team, collaborating with 18 experts, including neurosurgeons and plastic surgeons, to perform a successful upper-extremity transplant.

Ingari finds Johns Hopkins is on the forefront of both limb transplant and prosthetic design. "We're now developing prostheses that are on the verge of getting sensation back to patients. For some patients, that's the best option. For others, it's a transplant. We're pushing both envelopes at once."

He is particularly enthusiastic about the advances in understanding the basic science of chimerism, which have led to less need for anti-rejection

medications in transplant patients. "There's a lot more science that needs to be done to figure out how to avoid the need for immunosuppressants altogether. We're not there yet, but we're pushing," he says. The commitment to research in the hand division is strong, with orthopaedic surgery faculty

Fracture care, nerve regeneration, nerve repair

members currently involved in three multicenter trials exploring the areas of fracture care, nerve regeneration and nerve repair. "At Johns Hopkins," Ingari says, "we're always asking, how do we push ourselves forward?"

Ingari is also proud of the care Johns Hopkins offers to the youngest upper-extremity patients. "Pediatric patients have their own ORs, their own anesthesia team, their own nursing care facilities," he says. "We even have separate floors for teenagers, so we can really customize care by age group. The size of the institution allows that kind of specialization."

Ingari collaborates closely with plastic surgeons like Jaimie Shores, working together in a neuromuscular clinic to treat brachial plexus injuries. "We have geneticists on staff to help us understand whether patients have a syndromic condition versus a birth palsy," he says. "Some need surgery and some don't, and we work together to figure out the best approach for each patient."

As motivating as Ingari finds difficult cases of wrist reconstruction, elbow replacement and vascularized bone grafting, he is equally dedicated to treating more common conditions. "No surgery is mundane," he says. "I tell patients that small surgery is the kind somebody else has. For you, this is one of the bigger days of your life. I think that's a philosophy shared by all of our surgeons here. We treat even the straightforward surgeries with the greatest care." n

THOSE WHO GIVE

Recovering from Cancer with Expert Care and 5 `Little Motivators'

When you step into Karen Euculano's home, there is a sense of optimism and hope. She and her mother, who lives with her, make you feel that anything is possible. Faith is an integral part of their lives, and they believe that even the hardest experiences in life are valuable.

To understand Euculano's story, it's important to understand her energy level. She is a former triathlete who celebrated her 50th birthday by cycling 50 miles with friends at a brisk 18 miles per hour. Now, she cares for her 4-month-old granddaughter for 10 hours a day, five days a week. "I've never been a sedentary person," Euculano says.

So two years ago, when Euculano fell while playing a game of Kan Jam at the beach with her family, she was shocked that she couldn't stand up and bear weight. Over the coming days, she was diagnosed with a large, malignant solitary fibrous tumor that had destroyed much of her hip. It is a rare tumor that required special care.

Euculano received that care when she was referred to Adam Levin, orthopaedic oncologist at The Johns Hopkins Hospital. Levin, along with orthopaedic oncologist Carol Morris and team, performed a 12-hour surgery to remove

the tumor and replace damaged bone with cadaveric bone, metal plates, screws and wires. Through expert reconstruction, they were able to save her leg and restore her function.

"Dr. Levin was awesome," says Euculano. "He was very thorough, explaining treatment options, precautions, recovery and rehabilitation. I had my list of questions, and I never felt rushed.

"We did a lot of negotiating about my goals. Shortly after my surgery, my son and his wife had twins. Dr. Levin agreed that I could visit them in Pittsburgh if I stopped along the way." She also wanted to run again, she says, "so I could run after my grandkids!" She calls her five grandchildren, four of whom were born soon after her surgery, her "little motivators."

During her recovery, Euculano had tremendous support from friends and family, including her mother, a talented seamstress who crafted items to make Euculano more comfortable and functional--gadgets that helped her carry things on her walker and cloth bags filled with rice that could be used as cold packs. Together, mother and daughter supported each other with help from their health care team and community, tackling a difficult diagnosis with grace and strength.

Today, Euculano is cancer-free and nearly as active as ever. She practices tai chi to improve her balance, and she can put all her weight on the hip that was rebuilt. "I would recommend Dr. Levin to anybody," she says. "He is a good person and an excellent doctor. I truly believe I went to the best doctor for my diagnosis."

Euculano's generosity to the Johns Hopkins Department of Orthopaedic Surgery supports the work of physicians like Levin, who provide care every day so active patients can get on with their lives. n

COMPLEX CASES

"Dr. Levin was very thorough, explaining treatment options, precautions, recovery and rehabilitation. I had my list of questions, and I never felt rushed." -Karen Euculano

Supporting Our Work

The Johns Hopkins Department of Orthopaedic Surgery provides outstanding treatment of musculoskeletal disorders, fosters innovation and nurtures the next generation of orthopaedic surgeons. Our physician-scientists are leading the nation with groundbreaking research and innovations in patient care.

Your support for our research or the work of your doctor will help us better diagnose, treat and cure disabling conditions, such as scoliosis, osteoporosis, arthritis, trauma, bone cancer and soft tissue disease.

To help us through a tax-deductible gift, please visit philanthropy or call 410-955-6936.

Acute Fractures: From Treatment to Prevention

W hat initially attracted orthopaedic surgeon and traumatologist Babar Shafiq to join The Johns Hopkins Hospital were the challenge of complex cases and the opportunity to care for patients with severe injuries, often with multiple comorbidities. As a Level 1 trauma center, the Johns Hopkins facility attracts patients with some of the most difficult fractures to manage. Some patients come to Johns Hopkins from the local and regional area via ambulance or by air after acute injury, while many others are transferred from other hospitals

when their injuries or medical problems necessitate advanced care.

Shafiq accepts referrals of patients with severe, acute traumatic injuries of the pelvis and extremities, and those who have failed fracture management, nonunions, malunions or deformity. In addition, he is able to manage patients with these injuries who also have severe medical comorbidities that put them at higher surgical risk. "I routinely receive referrals from other doctors in our hospital system and from other local and regional hospitals for patients who have a fracture but are also very sick," says Shafiq.

The complexity of these cases requires Shafiq to team with specialists from other disciplines. "A patient may also have severe cardiac disease or have undergone an organ transplant. They may have kidney failure or a more obscure comorbidity, like osteogenesis imperfecta," says Shafiq. The multidisciplinary team may include specialists from interventional radiology, cardiothoracic surgery, endocrinology, transplant medicine, neurosurgery and general trauma surgery.

To offer patients the best possible treatments, Shafiq performs minimally invasive pelvic, acetabular and extremity surgeries whenever possible. He also participates in numerous research efforts to improve surgical technique and patient outcomes. Teamed with fellow orthopaedic trauma surgeon Erik Hasenboehler, the two lead biomechanical cadaver studies to investigate the

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RESEARCH

Fracture Risk and Treating Metabolic Disease: A Common Target?

Orthopaedic surgeons who treat patients with low bone mass may be particularly interested in the work of Ryan Riddle, director of the Johns Hopkins Diabetes Research Center's Bone Biology Subcore.

Riddle and his team have discovered a link among the protein, sclerostin-- which has a dramatic effect on bone mass--and whole-body metabolism. Riddle explains: "This protein was discovered recently by studying a small percentage of people who have very high bone mass. Their bone mass becomes so high that they start to develop nerve palsies because their nerve canals start to fill in [with bone] and they can't get nerve conduction. It's called sclerosteosis or Van Buchem disease." Sclerostin, which is made primarily in bone, was found to dramatically increase bone mass when inhibited.

Researchers in Riddle's lab, along with the lab of colleague Tom Clemens, are working to understand the interaction between bone and the metabolism of the whole organism. To that end, Riddle is using a knockout mouse model that lacks sclerostin.

"As we would expect from the human studies, this mouse has dramatic increases in bone volume," says Riddle. "But we've also discovered something else." When they challenge the mice with a high-fat diet, the mice don't gain body fat as expected. "They don't develop the phenotypes that are associated with diabetes in humans,"

Riddle says. "They retain some of their insulin sensitivity."

This indicates that the comorbid condition of low bone mass found in many patients with diabetes may be linked to sclerostin, potentially providing a common therapeutic target for both conditions. Riddle says this research may also be applicable to patients taking glucocorticoids, who are at risk for reduction in bone volume and increase in fat mass.

"Glucocorticoids are associated with changes in glucose homeostasis and insulin sensitivity," he says. "One of the ways glucocorticoids influence bone is through regulating sclerostin, so we're planning to explore sclerostin in that context too."

Riddle says his work benefits from the robust research environment at Johns Hopkins. "We have the ability to interact with many people in lots of different fields," he says. "Many of our studies are exploring effects outside the skeleton, like the physiology of adipose, the liver or the pancreas. We've benefited from the ability to collaborate with investigators like Michael Wolfgang in the Department of Biological Chemistry and Mehboob Hussain in the Department of Pediatrics. They are helping us move beyond the bone, which is our area of expertise."

This emphasis on integrative physiology is a hallmark of the work of musculoskeletal researchers at Johns Hopkins. By expanding their teams to

include experts in other fields and using the models their colleagues have developed for studying different organ systems, they not only strengthen their understanding of the musculoskeletal system, but also contribute more broadly to research that will underpin future therapies for a wide variety of common conditions. n

Genetic manipulation of the Sost gene that encodes sclerostin results in the dramatic increase in bone volume

evident in computer renderings of micro-computed tomography scans of the distal mouse femur, top, and

vertebrae, bottom.

treatment of complex pelvic and

ankle fractures. They are studying

minimally invasive treatments

for tibial plateau fractures and

alternative techniques for the

management of injuries to the

syndesmosis.

During the past year,

Shafiq has led the effort

to design and implement a

clinic to support bone health

in patients over 50. The Bone

and Joint Decade, a network

Babar Shafiq, left, and Andra Love, right, support a new clinic for bone health in patients over 50.

of organizations that position musculoskeletal conditions as a public health issue and is promoted by the

American Academy of Orthopaedic Surgeons,

encourages orthopaedists to promote cost-effective prevention and treatment of



musculoskeletal injuries and disorders. Shafiq and physician assistant Andra Love have partnered with Kendall Moseley, a bone health endocrinologist specializing in metabolic bone disease. Together, they have created a clinic that is focused on preventing secondary fractures and promoting bone health.

"Our clinic has been running for about six months now," says Shafiq. "We are identifying patients with fragility fractures and osteopenia or osteoporosis, and we're taking them through a diagnostic and treatment pathway to reduce their risk of future fractures."

When a patient needs a bone health examination, Love reviews the patient's risk factors for osteoporosis and fracture history to determine the risk of secondary fracture. Education is provided to help the patient understand the roles that calcium, vitamin D and exercise play in supporting bone health. Patients are given guidance concerning fall prevention and medication options. Dual-energy X-ray absorptiometry is used to evaluate bone density and, if necessary, patients are referred to Moseley for further treatment. Together, this bone health team constitutes a fracture liaison service that offers an individualized care plan for each patient. n

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A Legacy of Excellence

In the late 1800s, a Baltimore investor changed the course of history with one bold stroke of his pen by signing a bequest that would create The Johns Hopkins Hospital and inspire a revolution in American medicine.

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With your commitment, you are welcomed into the Johns Hopkins Legacy Society, honoring those who help to secure the financial future of Johns Hopkins Medicine.

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Framework Johns Hopkins Orthopaedic Surgery

Spring 2017

1 Pushing the Envelope for Upper-Extremity Injuries

2

Recovering from Cancer with Expert Care and five `Little Motivators'

3

Fracture Risk and Treating Metabolic Disease: A Common Target?

Inside

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